title: Clinical utility of EUS before cholangioscopy in the evaluation of difficult biliary strictures.
abstract: BACKGROUND
  Biliary tract malignancies can be assessed with either EUS or SpyGlass cholangioscopy (SGC).
  
  
  OBJECTIVE
  To evaluate the impact of EUS and guided biopsy before considering SGC in patients who had biliary strictures with negative ductal brushing.
  
  
  METHODS
  Prospective, observational study.
  
  
  METHODS
  Tertiary level referral hospital.
  
  
  METHODS
  Forty consecutive patients with biliary strictures.
  
  
  METHODS
  EUS evaluation and biopsy, where possible, were performed in all patients. If EUS examination failed to provide a definitive diagnosis, SGC and ductal biopsy was performed. Results were compared with surgical specimens or positive histocytology.
  
  
  METHODS
  Tissue diagnosis, technical success, adverse events, and clinical outcomes.
  
  
  RESULTS
  On EUS, abnormalities responsible for the biliary strictures were identified in 39 patients (98%), with FNA achievable in 30 patients (75%). EUS-FNA provided positive histocytology in 23 patients (58%). SGC-guided biopsy was performed to evaluate nondiagnostic EUS-FNA (17 patients) and to clarify autoimmune pancreatitis on FNA (2 patients). The procedure was successful in 18 patients (95%) and provided tissue diagnosis in 16 patients (88%), with 2 false-negative results from extrinsic pathologies. When EUS was used before the SGC approach, the need for SGC was avoided in 24 patients (60%), cholangitis was minimized in 2.5%, and a cost saving of U.S.$110,000 was realized. Tissue diagnosis was achieved in 38 patients (94%) with this approach.
  
  
  CONCLUSIONS
  Relatively small sample size.
  
  
  CONCLUSIONS
  EUS evaluation in patients with difficult biliary stricture prevents the need, cost, and adverse events of SGC in 60% of patients. Together, EUS followed by the SGC approach provides correct clinical diagnosis in 94% of patients with minimal adverse events.
authors.affiliation: Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Adelaide, South Australia; Department of Medicine, University of Adelaide, Adelaide, South Australia.
authors.forename: Nam Q
authors.initials: NQ
authors.lastname: Nguyen
authors.affiliation: Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Adelaide, South Australia.
authors.forename: Mark N
authors.initials: MN
authors.lastname: Schoeman
authors.affiliation: Surgical Pathology, SA Pathology, Adelaide, South Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ruszkiewicz
mesh_terms: D001327:Autoimmune Diseases / Q000150:complications / Q000175:diagnosis; D001650:Bile Duct Neoplasms / Q000150:complications / Q000473:pathology*; D001653:Bile Ducts, Intrahepatic / Q000473:pathology*; D018281:Cholangiocarcinoma / Q000150:complications / Q000473:pathology*; D015209:Cholangitis, Sclerosing / Q000150:complications / Q000473:pathology; D003251:Constriction, Pathologic / Q000209:etiology; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000009:adverse effects; D016145:Endoscopy, Digestive System / Q000009:adverse effects; D019160:Endosonography; D005260:Female; D005706:Gallbladder Neoplasms / Q000473:pathology*; D006801:Humans; D041781:Jaundice, Obstructive / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000150:complications / Q000473:pathology*; D010195:Pancreatitis / Q000150:complications / Q000175:diagnosis; D011446:Prospective Studies
keywords: AIP; MDCT; MRI; SGC; SpyGlass cholangioscopy; autoimmune pancreatitis; magnetic resonance imaging; multidetector CT